OMB Number: 4040-0001 Expiration Date 10/31/2019 APPLICATION FOR FEDERAL ASSISTANCE SF 424 (R&R) 3. DATE RECEIVED BY SIATE IIState Application Identifier 1I 1. TYPE OF SUBMISSION D Pre-application [g] Application D Changed/Corrected Application 2. DATE SUBMITTED 03/23/2017 II 4. a. Federal Identifier I I b. Ageocy Rootlog ldootlfle I I c. Previous Grants.gov Tracking ID I I Applicant Identifier II 5. APPLICANT INFORMATION Organizational DUNS: 16528138720000 I Legal Name: !National Health Laboratory Service I Department: I Division: I II Street1: 11 Modderfontein Road Sandringham I Street2: I I City: IJohannesburg I County I Parish: I I State: I I Province: IGauteng I Country: I ZAF: SOUTH AFRICA ZIP I Postal Code: I I I Person to be contacted on matters involving this application Prefix: lor. First Name: !Natalie I Middle Name: I II Last Name: IMayet I Suffix: I I Position/Title: I I Street1: 11 Modderfontein Road Sandringham I Street2: II City: IJohannesburg I County I Parish: I I State: I I Province: IGauteng I Country: ZAF: SOUTH AFRICA I ZIP I Postal Code: I I I Phone Number: 10113866038 Fax Number: I I I Email: Jnataliem@nicd.ac.za I 6. EMPLOYER IDENTIFICATION (E/N) or (TIN): 11-90021597 SA-1 I 7. TYPE OF APPLICANT: W: Non-domestic (non-US) Entity II Other (Specify): I I Small Business Organization Type D Women Owned D Socially and Economically Disadvantaged 8. TYPE OF APPLICATION: [g] New D Resubmission D Renewal D Continuation 0Revision If Revision, mark appropriate box(es). DA Increase Award DB. Decrease Award oc. Increase Duration DD. Decrease Duration D E. Other (specify): I I Is this application being submitted to other agencies? Yes D No [g] What other Agencies? I I 9. NAME OF FEDERAL AGENCY: !centers for Disease Control and Prevention - El 10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER: 193. 32 6 TITLE: !Protecting and Improving Health Globally: Strengthening Public Health through Surveillance, Epidemiologic Research, 11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT: !Supporting the National Health Laboratory Service to expand public health research on Field and Lab investigations as well as to incorporate results of research into operational health promotion I 12. PROPOSED PROJECT: Start Date Ending Date I 09/30/2017 09/30/2022 11 I 13. CONGRESSIONAL DISTRICT OF APPLICANT Joo-ooo I SF 424 (R&R) APPLICATION FOR FEDERAL ASSISTANCE Page 2 14. PROJECT DIRECTOR/PRINCIPAL INVESTIGATOR CONTACT INFORMATION Prefix: IProf. I First Name: jshabir I Middle Name: I I Last Name: IMadhi I Suffix: I I Position/Title: !Executive NICO I Organization Name: lwational Health Laboratory Service I Department:jw I co Division: II Street1: 11 Modderfontein Road I Street2: II City: IJohannesburg I County I Parish: I I State: I I Province: IGauteng I Country: ZAF: SOUTH AFRICA ZIP I Postal Code: I I II Phone Number: 10113866137 Fax Number: I II Email: lshabirm@nicd.ac.za I 15. ESTIMATED PROJECT FUNDING 16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 PROCESS? a. YES D THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON: DATE: I I b. NO [8_] PROGRAM IS NOT COVERED BY E.O. 12372; OR D PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW a. Total Federal Funds Requested lsoo, ooo. oo I b. Total Non-Federal Funds lo. oo I c. Total Federal &Non-Federal Funds lsoo, ooo. oo I d. Estimated Program Income lo. oo I 17. By signing this application, I certify (1) to the statements contained in the list of certifications* and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances* and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious. or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 18, Section 1001) [8] I agree 'The list of certifications and assurances, or an Internet site where you may obtain this list, is contained In the announcement or agency specific instructions. 18. SFLLL (Disclosure of Lobbying Activities) or other Explanatory Documentation I Add Attachment ii Delete Attachment ii I View AttachmentJI 11 I 19. Authorized Representative Prefix: IMs. First Name: IRefiloe Middle Name: I I II Last Name: IMochochoko Suffix: I II Position/Title: IProgramme Manager I Organization: lwational Health Laboratory Service I Department: !Grants Division: I I Street1: 11 Modderfontein Road I Street2: II City: IJohannesburg I County I Parish: I State: I Province: IGauteng II Country: I ZAF: SOUTH AFRICA I ZIP I Postal Code: J I Phone Number: 1+27113866249 I Fax Number: I I Email: jrefiloe.mochochoko@nhls.ac.za I Signature of Authorized Representative Date Signed Completed on submission to Grants.gov I Completed on submission to Grants.gov I II 20. Pre-application I Add Attachment 1 loelete Attachmentll I; View Attachment II 11 21. Cover Letter Attachment I Add Attachment ~ I Delete Attachmentii I: View Attachment I 11 RESEARCH & RELATED BUDGET- Budget Period 1 ORGANIZATIONAL DUNS: 16528138720000 I Enter name of Organization: !National Health Laboratory service Budget Type: [g] Project D Subaward/Consortium Budget Period: 1 Start Date: 109/30/20171 End Date: A. Senior/Key Person OMB Number: 4040-0001 Expiration Date: 10/31/2019 -I l10/301201sl Months Requested Fringe Funds Prefix First Middle Last Suffix Base Salary ($) Cal. Acad. Sum. Salary ($) Benefits ($) Requested ($) !Prof. lshabir I IMadhi I I o.ool a.aal a.aal Project Role: PD/PI ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~---' Additional Senior Key Persons: I Add Attachment ] IDelete Attachmentl I View Attachment '.In Total Funds reqm~sted for all Senior . - - . ~ Key Persons m the attached file ' TotaI Senior/Key Person I a. aal B. Other Personnel Number of Months Requested Fringe Funds Personnel Project Role Cal. Acad. Sum. Salary ($) Benefits ($) Requested ($) al Post Doctoral Associates a.aal I a.aal a.aal CJI ICJ :=:=====~ ol Graduate Students C J C J C J a.aal a.aal a.aal ::======~ al Undergraduate Students C J C J C J a.aal a.aal a.aal :===========: al Secretarial/Clerical C J C J I I a.aal a.aal a.aal ~=======: 141 lstaff Required for all activities C J C J C J I 342,279.aal o.aal 342,279.aal L____l_4_JI Total Number Other Personnel Total Other Personnel 342, 279---~I Total Salary, Wages and Fringe Benefits (A+B) 342,279.aal C. Equipment Description List items and dollar amount for each item exceeding $5,000 Equipment item Funds Requested ($) Includes all equipment. The detailed budget is attached f-- 19,972.oof -rn Additional Equipment: I Add Attachment JI lo~l~t~ Attachment 11 View Attachment ~ Total funds requested for all equipment listed in the attached file Total Equipment I 19,972.oof D. Travel Funds Requested ($) 1. Domestic Travel Costs (Incl. Canada, Mexico and U.S. Possessions) 17, 484. oaf 2. Foreign Travel Costs Total Travel Cost 17, 4s4. oof E. Participant/Trainee Support Costs Funds Requested ($) 1. Tuition/Fees/Health Insurance 2. Stipends 3. Travel 4. Subsistence 5. Other L=i Number of Participants/Trainees Total Participant/Trainee Support Costs F. Other Direct Costs Funds Requested ($) 1. Materials and Supplies 49,181.0ol 2. Publication Costs o. ool 3. Consultant Services 4. ADP/Computer Services 5. Subawards/Consortium/Contractual Costs 6. Equipment or Facility Rental/User Fees 7. Alterations and Renovations 8s.. !This includes other for whole Details are attached I 40,364.ool all costs the programme. 10. Total Other Direct Costs I 12 o, 2 65. ool G. Direct Costs Funds Re uested $ Total Direct Costs (A thru F) 500,000.00 H. Indirect Costs Indirect Cost Type Indirect Cost Rate(%) Indirect Cost Base($) Funds Requested ($) Total Indirect Costs Cognizant Federal Agency (Agency Name, POC Name, and POC Phone Number) I. Total Direct and Indirect Costs Total Direct and Indirect Institutional Costs (G + H) 500, ooo. oo J. Fee Funds Requested($) II K. Total Costs and Fee Total Costs and Fee (I + J) 500,000.00 L Budget Justification (Only attach one file.) Iconducting Public Health Research in ~I L -~d~ Atta_chme~_t_J I Delete Attachment 11 View Attachf11e~t J RESEARCH & RELATED BUDGET- Cumulative Budget Totals($) Section A, Senior/Key Person o. ool Section 8, Other Personnel 342,279.ool Total Number Other Personnel 14 Total Salary, Wages and Fringe Benefits (A+B) I 342,279.ool Section C, Equipment I 19,972.ool Section D, Travel I 17,484.ool 1. Domestic 17,484.ool 2. Foreign Section E, Participant/Trainee Support Costs 1. Tuition/Fees/Health Insurance 2. Stipends 3. Travel 4. Subsistence 5. Other 6. Number of Participants/Trainees Section F, Other Direct Costs 120,265.ool 1. Materials and Supplies 49, 181. ool 2. Publication Costs o. ool 3. Consultant Services 30, no.ool 4. ADP/Computer Services 5. Subawards/Consortium/Contractual Costs 6. Equipment or Facility Rental/User Fees 7. Alterations and Renovations 8. Other 1 I 40,364.ool 9. Other2 10. Other 3 Section G, Direct Costs (A thru F) 500, ooo. ool Section H, Indirect Costs Section I, Total Direct and Indirect Costs (G + H) I 500,000.ool Section J, Fee Section K, Total Costs and Fee (I + J) I 500,000.ool PHS 398 Research Plan OMB Number: 0925-0001 Expiration Date: 10/31/2018 Introduction 1. Introduction to Application 11 Add Attachment IJ Joelete Attachment~ IView AttachmentJI I (Resubmission and Revision) Research Plan Section 2. Specific Aims I 11 Add Attachment iJ Joelete Attachment~ IView Attachment ii 3. *Research Strategy Iconducting Public Health Re I JAdd Attachment !J jQele!QhttachmeQUJ J View Attachment~ 4. Progress Report Publication List I 11 Add At~chment] jDelete Attachment!J VLe)!..f\tlachment ~ J Human Subjects Section 5. Protection of Human Subjects I 11 Add Attachment ~ IDelete Attachment!! 6. Data Safety Monitoring Plan I 11 Add Attachment ii IDelete Attachmicl 7. Inclusion of Women and Minorities I I LA<id Attachment~ Joelete AttachmentiJ 8. Inclusion of Children I I Lf-dd Attachme!!Lll J,peiete AttachmentiJ I View Attachment ! IView Attachment i IView Attachment II J View Attachment i Other Research Plan Section 9. Vertebrate Animals 10. Select Agent Research 11. Multiple PD/Pl Leadership Plan 12. Consortium/Contractual Arrangements 13. Letters of Support 14. Resource Sharing Plan(s) 15. Authentication of Key Biological and/or Chemical Resources I 11 Add Attachme11d IDelete Attachmentll I 11 Add Attachment i Jnelete Attachment!J I I Delete AttachmentiJ I JA<!Q.6!lachment ~ I I J,,Add Attachment ~ I \I Add Attachment ii I 11 Add Attachment ii I 11 Add Attachment~ IDEfiltle Attachm~J JDelete AttachmentlJ IDelete Attachmentil jDelete Attachment!J J View Attachment !J J View Attachment~ J View Attachment ii J View Attachment ii IView Attachment iJ IView Attachment II J View Attachment ii Appendix 16. Appendix I Add Attachments i I Delete Attact1me_ntsJI I:iew Attachments II ACCESSION #90010494 RFA-GH-17-003 1 U01GH002223-01 PHS 398 Cover Page Supplement OMB Number: 0925-0001 Expiration Date: 10/31/2018 1. Human Subjects Section Clinical Trial? D Yes [gj No *Agency-Defined Phase Ill Clinical Trial? D Yes D No 2. Vertebrate Animals Section Are vertebrate animals euthanized? D Yes [gj No If Yes to euthanasia Is method consistent with American Veterinary D Yes Medical Association (AVMA) guidelines? If No to AVMA guidelines, describe method and provide scientific justification 3. *Program Income Section *Is program income anticipated during the periods for which the grant support is requested? 0Yes [gj No If you checked yes above (indicating that program income is anticipated), then use the format below to reflect the amount and source(s). Otherwise, leave this section blank. *Budget Period *Anticipated Amount($) *Source(s) C=:J l~--~I 4. Human Embryonic Stem Cells Section *Does the proposed project involve human embryonic stem cells? D Yes [gj No If the proposed project involves human embryonic stem cells, list below the registration number of the specific cell line(s) from the following list: http://stemcells.nih.gov/research/registry/. Or, if a specific stem cell line cannot be referenced at this time, please check the box Indicating that one from the registry will be used: D Specific stem cell line cannot be referenced at this time. One from the registry will be used. Cell Line(s) (Example: 0004): II PHS 398 Cover Page Supplement 5. Inventions and Patents Section (RENEWAL) *Inventions and Patents: Yes D No D If Yes then answer the following: *Previously Reported: Yes D No D 6. Change of Investigator I Change of Institution Section D Change of Project Director I Principal Investigator Name of former Project Director/Principal Investigator: Prefix: I I :==================----~~~~~~ *First Name: I I :=======================::;-~~~ Middle Name: I I ~===============-----~~~~~~~~~---, *Last Name: I I :::=============:::;-~~~~~~~~~~~~-----' Suffix: I I '--~~~~~~~~ D Change of Grantee Institution *Name of former institution: II RESEARCH & RELATED Other Project Information OMB Number: 4040-0001 Expiration Date: 10/31/2019 1. Are Human Subjects Involved? D [gj No Yes 1.a. If YES to Human Subjects Is the Project Exempt from Federal regulations? D Yes D No If yes, check appropriate exemption number. 0 1 0 2 0 3 0 4 0 5 0 6 If no, is the IRB review Pending? D Yes D No IRB Approval Date: L--~;::::======-~~~~ Human Subject Assurance Number: ~---------' 2. Are Vertebrate Animals Used? 0Yes [gj No 2.a. If YES to Vertebrate Animals Is the IACUC review Pending? D Yes IACUC Approval Date: ~~~--;::::==::'...__~~~~~ Animal Welfare Assurance Number: ' ' 3. Is proprietary/privileged information included in the application? 0Yes [gj No 4.a. Does this Project Have an Actual or Potential Impact - positive or negative - on the environment? D Yes [gj No 4.b. If yes, please explain: '--------~ ~ 4.c. If this project has an actual or potential impact on the environment, has an exemption been authorized or an environmental assessment (EA) or environmental impact statement (EIS) been performed? D Yes D No 4.d. If yes, please explain: ~' 5. Is the research performance site designated, or eligible to be designated, as a historic place? 0Yes [gj No 5.a. If yes, please explain: '' 6. Does this project involve activities outside of the United States or partnerships with International collaborators? [g) Yes 6.a. If yes, Identify countries: south Africa ~ 6.b. Optional Explanation: '' 7. Project Summary/Abstract conducting Public Health Research co, L=~ Attachment .~ I Delete Attachment~ I View Attachment 8.